IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)

e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 14, Issue 4 Ver. III (Apr. 2015), PP 14-18
www.iosrjournals.org

Incidence of Hypothyroidism in Antenatal Women with Maternal

and Perinatal Outcome
Dr. K. Padmavathi*, Dr.Ch. Prasanna**
Dept. ofObstetric&GynaecologyAndhra Medical College, Visakhapatnam, Andhrapradesh.
*Asst.Prof. Of Gynaecology, ** Senior Resident

I.

Introduction

Thyroid disorders are the most common endocrine disorders affecting the women of reproductive age
group and hence constitutes the common endocrine disorder in pregnancy also. It has long been recognized that
maternal thyroid hormone excess or deficiency can influence the outcome for mother and fetus at all stages of
pregnancy as well as interferes with ovulation and infertility(1).
Maternal hypothyroidism is the most common disorder of thyroid function In pregnancy and has been
associated with miscarriage, fetal loss, preeclampsia, preterm labour, placental abruption, tow birth weight, fetal
distress and reduced intellectual function of the offspring These adverse outcomes have been associated with
both overt hypothyroidism (elevated TSH and reduced free T4) found in about 0.2% of pregnancies as wed as
subclinical hypothyroidism (elevated TSH and normal free T4 concentration) found in about 2 3%
Thyroid dysfunction is often overlooked in pregnant women because of the nonspecific symptoms and
the hyper metabolic state of pregnancy. Hence thyroid function test becomes essential to know the thyroid status
in pregnancy and also to detect the subclinical disease.(3-5)
In view of the potential for serious adverse effects associated with maternal thyroid disease and the
apparent benefits of treatment many have recommended routine thyroid function screening in pregnancy.
As hypothyroidism would be a cause of a number of pregnancy and perinatal complications there is
increasing need for screening of every antenatal women for thyroid disorder Hence this study is undertaken to
find the significanceof the relation between the adverse outcomes in pregnancy and hypothyroidism.(6)

II.

Review Of Literature

The role of thyroid hormone for brain development and cognitive function:
Endo.dev 2014;26 26 Revet JE : Through its actions on regulatory genes that form, grow and sculpt the
brain, thyroid hormone (TH) is essential for human brain development Children exposed to thyroid
insufficiencies during critical stages of early development shows how and when brain needs thyroid hormone.
This paper reviews some of the major studies form offspring of women with hypothyroidism during pregnancy
and children with congenital hypothyroidism who were assessed using neuropsychological tests and with
advanced neuroimaging techniques and compared, To know the time when the Thyroid effects on 1he brain.(7)
The effects of thyroid hormone function in early pregnancy
Bemardi L A current opinion Obstetrics and Gynecology 2013;25(4) : The multiple societies have
published guidelines on thyroid disease in pregnancy but have not advocated universal screening however recent
studies suggest close monitoring of women with hypothyroidism though there is lack of evidence that treatment
of overt hypothyroidism improves the maternal and fetal complications.(8)
Prevalence of subclinical and undiagnosed overt hypothyroidism in a pregnancy loss clinic
IR Med journal2013;106(4)107-10 : The prevalence of complications in these two groups of women
were studied showing increased rates of miscarriages, late miscarriages intrauterine deaths and still births.262
women included in the study with subclinical (8.39%) and overtly hypothyroid women (3.05%)Showing its
association with unexplained pregnancy losses (10)
Maternal and fetal complications of hypothyroidism related to pregnancy
Maedica2013;5(2)-116-123 : Thyroid pathology worsens during pregnancy. This study was done to
know the complications during pregnancy, labour and postpartum period. They found increased incidence of
preeclampsia and preterm births. They have found thatlabour is dyskinetic with fetal distress and after birth with
low APGAR and postpartum hemorrhage The indication for caesarean operation was mainly fetal distress.(11)

DOI: 10.9790/0853-14431418

www.iosrjournals.org

14 | Page

Incidence Of Hypothyroidism In Antenatal Women With Maternal And Perinatal Outcome

Hypothyroidism
Hypothyroidism is due to underactive thyroid gland means that the thyroid gland can't make enough
thyroid hormone for normal body functions. Incidence of Hypothyroidism is 2.5% in the antenatal women In
endemic areas like coastal regions of Andhra Pradesh incidence is 6-8/100 women.
The incidence is very much high when compared to studies done in general population like Sharma Partha P et
al.,(l999) which showed an incidence1,15%.In a recent study conducted in 2011 by Nambiar el al.. the incidence
wasfound to be 5.2%in antenatal womenAnother study by Cleary-Goldrnan.et al., showed an incidence of <1%
withovert hypothyroidism and 2.2% with subclinical hypothyroidism.(12)
Dignosis Of Neonatal Hypothyroidism
Ideally serum TSH and T3 are estimated from an elute of whole blood collected on filter paper by a heel
prick between 4lh and 6rrt days of life. If the screening blood TSH is more than 40mU/lh then the child is called
for retesting but treatment is not indicated unless rising levels are documented (13)
Specific reference range values of thyroid hormones
Test

Non
pregnant

1s1
trimester

2nd
trimester

3rd trimester

Cord blood

SrT4 mcgJdl
Free T4ngWI
SrT3 agM
Free T3 pg/dl
SrTSHUM
Reverse T3 ng/dl
Rosin T3 % uptake
TBG g/dl

5-12
1-2.3
110-230

1G+_0.25
0.86-1 77
174+_6
1.91-3.5
0.03-2.3

10-f_0.26
0.63-139
182.6+_6.3
2.8-4.2
0.03-3.7

10.1+_029
0.16-1,12
208.2+_7.18
2.4 - 4.1
0.13 - 3.4

6-13
15-3
40-60

1548+J.96

14.92+_2.05

1B.55*_28

1.94
15-30
20-30
12-28

III.

0-20
80-360
10-15
10-16

Materials And Methods

A random prospective study was conducted in a total of 1000 pregnant women in the first trimester of
any gravid status and parity attending the OPD unit at Government Victoria Hospital. Visakhapatnam, Andhra
Pradesh between November 2013 to September 2014 were included in the study,
Inclusion criteria
Antenatal women with < 12 Weeks Gestation were taken up for study Only Singleton Pregnancy were
includedEither primigravida or multigravida were selected randomlyAntenatal women who are residents of
Visakhapatnam and who can come for regular antenatal checkups were chosen for my study
Exclusion Criteria
Antenatal women with Multifetal gestation
Antenatal women with Known chronic disorders like" Diabetes and HTN
Pregnant women with had previous bad obstetric history with known cause
Those who underwent surgery for thyroid or a known case of thyroid
Method
After obtaining informed consent from the patient detailed history along with review of previous
records will be taken in a prescribed proforma with emphasis on any previous medical complications, past
history of thyroid disease physical examination was done to look for thyroid enlargement and to ascertain the
pregnancy. 1000 patients in 1st trimester were randomly selected for the study. These patients fulfilled all the
inclusion criteria, A detailed history was taken regarding the symptoms, and signs of thyroiddisorders.
Menstrual history, obstetric history, past history medical history, family history, personal historyA thorough
general physical examination with reference to pulse, BP,temperature, respiratory rate followed by examination
of the CVS, CNSP respiratory system local and thyroid examination.Per abdomen examination and Per Vaginal
examination done and pregnancy confirmedPatients are sent for T3.T4, TSH testing to a standard lab and
following reference range was used (profile estimated by chemiluminiscent method)
Depending upon the fasting T3 and T4, TSH values they are grouped asSubclinical/Overt
hypothyroidismIf they are subclinical/overt hypothyroid, Thyroxin is started.Every 8 weeks TSH level will be
estimated and the dose of the drug adjusted at the end, the pregnancy outcome noted.
The following outcome variables in relation to thyroid disorders studiedMiscarriages Preterm deliveries
IUGR, Preeclampsia, Anemia, Low birth weight, intra uterine fetal demise, Antepartum hemorrhage, Stillborn,
Mode of deliveries- rate of normal,instrumental or caesarean, Postpartumhemorrhage, Birth asphyxia

DOI: 10.9790/0853-14431418

www.iosrjournals.org

15 | Page

Incidence Of Hypothyroidism In Antenatal Women With Maternal And Perinatal Outcome

IV.

Discussion

Thyroid disorders are common in pregnant women. Diagnosis of thyroid dysfunction is complicated by
nonspecific symptoms, hyper metabolic state of pregnancy and normal gravid thyroid physiology which results
in alteration in maternal serum TSH and thyroxin concentration, if untreated, hypothyroidism may adversely
affect the mother and the fetus. Earlier studies have reported an increased association with congenital anomalies
(10-20%), perinatal mortality (20%}fand impaired mental and somatic development (50- 60%) in newborns of
untreated hypo thyroid women
The present study was conducted in Government Victoria Hospital in 1000 antenatal women attending
antenatal op selected randomly and screened thyroid disorder It was a prospective study and the mam aim of the
study now the incidence of new cases of hypothyroidism in antenatal women their obstetric outcome.
Incidence
With the laboratory reference range used to detect hypothyroidism the number of cases found to have
the disease were 66 which is highly significant The incidence is very much high when compared to studies done
in general population like Sharma Partha P which showed an incidence of 1.15%. In a recent study conducted in
2011 by Nambiar et al,, the incidence was found to be 5.2% nearly comparable to our study. Another study by
Cleary-Goldman et al.h showed an incidenceof <1% with overt hypothyroidism and 2.2% with Subclinical
hypothyroidism Casey et al,.reported an overall incidence of hypothyroidism to be 2,5 %,This indicates that
thyroid function screening is a necessary Investigation in patients who had a previous adverse pregnancy
outcome.
Incidence of Complications in Sub-clinical Hypothyroidism
Study

PE

Our Study
Leung
SahuetaL,

17%
15%
9.9%

AP

PTD

AB

10.6%
9%
10.3%

4,2%

JUGR
4.2%

LBW
6.3%
9%

2.4%

SB
2.1%
2.5%

In a study done by Leung et al the incidence of complications were PE (15%). PTD (9%), LBW (9%)
in cases of subclinical hypothyrokJism. which ts slightly more than our study.
In a study done by Sahu MT et al68, the complication like PE (9.9%), PTD (10.3%). IUGR (2,4%),
38(2.5%) were seen in cases of sub-clinical hypothyroidism. In these two studies there was no incidence of
abruption placenta and abortion, but in our study it is 1.4% and 4.3% respectively which is significant.
In our study subclinical hypothyroidism was associated with complications preeclampsia (17%),
preterm delivery (10.5%). which are comparable to studies. IUGR (4.2%) slightly higher in our cases., LBW
(6.3%) and still 11 case mounting to 2.1%. In these two studies there is no incidence of but in our study, it is
42%, which is significant.In a study by Roli et al., even in LT4 treated pregnant hypothyroid creased rate of
maternal complications such as anemia (31%). 44%) placenta! abruption (19%) postpartum hemorrhage seen
in women not accurately monitored, and
fetal ft as low birth weight (31%) and fetal death (12%) have been
reported.
In our study the incidence of anemia was 8.5% which was less than that of Roti el al. which might be
due to increase awareness on the use of iron supplement and healthy nutritious diet antenatal woman and good
monitoring of thyroid status with treatment.
Incidence of complications in Overt Hypothyroidism
Study
Out Study
Leung
SahuEtal.,
Ablovich

PE
31.%
22%
20.%

AP
10.%

PTD
10.5%
4.7%

AB
15.%

IUGR
15.%

LBW
15.7%
22%

13.8%

19%

6%

SB
5.%
4%
2.9%
3%

In our study, overt hypothyroidism was associated with complications like PE (31.5%), AP (10.5%),
PTD (10.5%). AB (15.7%), |UGR (15.7%), LBW (15.7%), SB (5.2%).
In a study done by SahuMTet al68, the complications like PE (20.7%). PTD (4.7%), IUGR (13.8%,
SB(2.9%) were seen in cases of overt hypothyroidism.
In a study done by Leung et al, the incidence of complications were PE(22%), LBW (22%), SB (4%) in
cases of overt hypothyroidism.
In a study done by Abotovichet al71 the complicates like AP (19%). LBW (8%), SB (3%) were seen in
cases of overt hypothyroidism. The incidence of complications varied i n different studies but some studies are
comparable. In our study the incidence of abortion (15.7%) which is significant and is not seen in other studies..

DOI: 10.9790/0853-14431418

www.iosrjournals.org

16 | Page

Incidence Of Hypothyroidism In Antenatal Women With Maternal And Perinatal Outcome

A clinical study by DANIA Hirsch et al from 2009-2010 found that in cases with TSH>20Miu/l are
associated with more severe form of gestational hypertension. This is comparable to our study as the maternal
complications including hypertension are more in women with TSH>18m IU I.
A study by Rao VR et al..demonstrated the relationship between hypothyroidism and miscarriages This
is also demonstrated in our study the relation of hypothyroidism with miscarriage.
Study by Jane dearyGoldmann (1999) showed that Hypothyroxemiais associated with preterm labour.
Which is also found in our cases in might be due to placenta! insufficiency occurs in these cases.Davis L S
elal..(1988) found that maternal complications are more common in hypothyroid women anemia (30%),
preeclampsia (44%). APH (19%)hpretermlabour (19%). BW(31%).IUFD{12%)r PPH (19%).(13-14)
A study by VojVodic LJ et al., (1981-1990).in 183 women found significant higher incidence in
preeclampsia in hypothyroid women (26.8%). This is comparable to our study and most of our cases were on
cap depin and Tab Labetol till delivery. This is especially seen in overt cases
Table- Pregnancy Outcomes in Women with Untreated Subclinical Hypothyroidism and Isolated
Maternal Hypothyroxemia Compared with Pregnant Women with Normal Thyroid Function Studies

Hypertension (%}
Placenta! abruption (%)
Gestational age delivered (%)
36 weeks
34 weeks
32 weeks
RDS ventilator (%)
Neonatal intensive care

Norma TSH and Free Subclinical

P value
T4 (n=16,011)
Hypothyroid Ism (n =
598)

Isolated
(n = 233)

Hypothyroxemia P value

G
0,3

9
10

.68
.03

11
0.4

.53
.75

6.0
2.5
1.0
1.5
2,2

7.0
43
2.2
25
40

.09
.005
13
.05
.005

6,0
2.0
1.0
1.3
1.3

.64
M
.47
7&
.32

RDS = Respiratory distress syndrome; T4 = thyroxine; TSH = thyroid-stimulating hormone.

Data from Casey and colleagues (2007)
A separate study reported a markedly increased use of caesarean section because of fetal distress in
women who were severely hypothyroid (56%) at their first antenatal visit compared with women who were
mildly hypothyroid or euthyroid (3%). Even in our study there is increased rate of caesarean section and some
instrumental deliveries in overt hypothyroid than subclinical hypothyroid mainly in view of fetal distress and
some in view of prolonged labour.
Incidence of low birth weight neonates is markedly increased in cases of Overt hypothyroidism (22%)
compared with subclinical disease (95) and the general population (7%), Research also shows the significant
role of maternal thyroid hormone in fetal neurologic development
Table - Thyroid dysfunction in first trimester pregnant women by Dinesh et al. study
Parameters
Hypothyroidism total
Overt hypothyroidism
Subdmical hypothyroidism

N%
143(14.3)
7(07)
135(135)

Anti TPOAb
30(20.9)
5
25(18.%)

Our study shows high incidence of Hypothyroid especially subclinicalhypothyroidism with associated
adverse pregnancy outcome which were more with overt hypothyroidism.
Based on the results of the present study we therefore suggest for a mandatory screening for antenatal
women in the first trimester of pregnancy and detection of thyroid dysfunction among pregnant women
attending to routine antenatal clinic and to be potentially aware of associated maternal and fetal
complications.All the babies were screened for TSH on the 5 th post natal day but no baby had shown features
of congenital hypothyroidism. The weakness of our study was that, follow up beyond newborn period was not
possible and after discharge most infants did not come for follow up.
Summary
The present study was conducted in Government Victoria Hospital Andhra Medical College,
Visakhapatnam. It is a prospective study. It included screening of 1000 pregnant women coming to routine
antenatal check up their first trimester, TSH, T3, T4 level was estimated.
The incidence of thyroid disorders in our study was 6.6%,
The incidence of subclinical hypothyroidism in our study was 47%,
The incidence of overt hypothyroidism in our study was 1.9%.
DOI: 10.9790/0853-14431418

www.iosrjournals.org

17 | Page

Incidence Of Hypothyroidism In Antenatal Women With Maternal And Perinatal Outcome

In our study, subclinical hypothyroidism was associated with complications like
PE (17%), PTD
(10.6%), AB (4.2%), IUGR (4.2%). LBW(6-3%), SB (2.1%)
Overt hypothyroidism was associated with complications like PE (31.5%), AP (10 5%}, PTD (10.5%),
AB (157%),IUGR (157%), LBW (157%), SB (52%). IUD is seen in 1 case of subclinical and 2 cases of overt
hypothyroidism.Most of the parameters are comparable to other studies with minimal variations with high
incidence of preeclampsia in our study.Incidence of thyroid dysfunction was high in this study, with subclinical
hypothyroidism in (4.7%) and overt hypothyroidism in (1.9%) women.

V.

Conclusion

Incidence of Hypothyroidism {6,6%) is more in pregnant women. Though Subclinical hypothyroidism

is more common than oven, maternal and perinatal complications are more with overt hypothyroid cases,
emphasizing the need for routine screening for thyroid in early pregnancy. Thyroid function tests need to be
included in the list of antenatal investigations done in antenatal women in view of high incidence of
hypothyroidism seen in pregnant women.

References
[1]. Kim E Barrett, Barman SM et al. The thyroid gland. Ganongs Review of medical physiology, 23 rd edition, 2010: 301-340.
[2]. Kasper DL. Brauwald E et al. Disorders of Thyroid Gland. Harrisons Principles of Internal Medicine, 16 th edition, Vol. 2, 2005 :
2104-2126.
[3]. ChowdarySujit, The Thyroid, Medical Physiology 6 th edition, 2008: 276-281.
[4]. Guyton & Hall, Thyroid Metabolic Hormones. Textbook of Medical Physiology, 11th edition, 2006: 931-943.
[5]. Cunningham, Thyroid and other endocrine disorders. Williams obstetrics, 23 rd edition, 2010: 1126-1144.
[6]. John Studd, Thyroid Hormones in pregnancy and foetus, 15 th edition, 75-102.
[7]. Glinoer D, De Bayer P, Bourdoux P et al. Regulation of maternal thyroid during pregnancy. J. Clin. Endocrinol. Metab. 1990:71(2):
276-287.
[8]. Lee RH, Spencer CA, Mestman JH et al. Free T4 immunoassays are flawed during pregnancy. Am. J. Obstet. Gynecol. 2009:200(3):
260 et1-e6.
[9]. Kurioka H, Takahasshi K, Miyazaki K. Maternal thyroid function during pregnancy and puerperal period. Endocr. J. 2005:52(5): 587591.
[10]. Yoshimura M, Hershman JM. Thyrotropic action of human chorionic gonadotropin. Thyriod 1995:5:425-34.
[11]. Corinne R. Fantz, Samuel Dagogo-Jack, Jack H Ladenson et al. Thyroid function during pregnancy. Clinical Chemistry 1999:45(12):
2250-2258.
[12]. Fister P, Gaberscek S, Zaletel K, Krhin B, Hojker S, Gersak K. Thyroid function in the third trimester of pregnancy and after deliver
in an area of adequate iodine intake. Int. J. Gynaecol. Obstet. 2011: 112(1):52-55.
[13]. Berghout A, Wiersinga W. Thyroid size and thyroid function during pregnancy : an analysis. Eur. J. endocrinol. 1998: 138(5): 536542.
[14]. Haddow JE, McClain MR, Lambert-Messerlian G et al. Variability in thyroid-stimulating hormone suppression by human chorionic
gonadotropin during early pregnancy. J. Clin. Endocrinol. Metab 2008: 93(9): 3341-3347

DOI: 10.9790/0853-14431418

www.iosrjournals.org

18 | Page